SOCIO-CULTURAL DIMENSIONS OF REPRODUCTIVE HEALTH PROBLEMS

Transcription

1 CHAPTER 5 SOCIO-CULTURAL DIMENSIONS OF REPRODUCTIVE HEALTH PROBLEMS Socio-cultural profile of the respondents This chapter deals with health problems of our respondents during the reproductive period. Here, we are examining the different socio-cultural factors that have significant bearing on reproductive health problems during the ante-natal, natal and post natal periods. We have identified the different ailments during the three stages of the reproductive period, treatment taken during the three stages, reproductive morbidity, gynecological problems and menstrual problems. All these have been related to the socio cultural factors of age, education, occupation, income and religion. The hypothesis that we have formulated on this basis is that Socio cultural factors have significant influence on problems of reproductive health and pattern of illness The studies that we have cited in the previous chapters, especially in Chapter 3, review of literature, have identified several reproductive health problems of women in different parts of the world including India and factors which have stood in the way of women availing health care facilities even when heavy promotional work had been made by governments and even when these measures were intended for their better health and wellbeing. It is well known that beliefs and practices, whether based on tradition or 145

2 convention, have been found to have a strong influence even on educated persons the world over and they cannot be easily overcome by marshalling scientific proof. Women have a greater vulnerability to traditional beliefs and such beliefs are more concentrated around pregnancy and child birth than on other areas of life. Naturally, a student of reproductive health cannot ignore such elements in the tradition nor can he/she find fault with the believer when the latter tries to put it into practice. Our study being a descriptive one has not attempted to make any value judgments on practices based on such beliefs. Since we were concerned with their influence on reproductive health we have identified them and examined their influence on our respondents behaviour. For the location of such behavior, we have identified some variables and described them in some details because they are key to the understanding and analysis of our problem, viz., behaviour of our subjects. The variables so identified are current age, age at marriage, education, occupation, income, religion and pregnancy health related variables. Also included in the data collection and for obvious reasons are husband s age, education, income and occupation. These are also the socio-cultural variables that we have used as determinants of reproductive behavior. Age Age expresses the biological factor of the individual personality and it also affects the attitude of individual towards life. Age has a direct impact on the thinking pattern of the individuals and their views and opinions regarding 146

3 their respective age. Age is an important determinant while considering fertility and is also important from the health point of view. In the study, since we concentrate on current levels of reproductive health of women, it is important to study the present age pattern of these women. Age is classified into seven equal intervals ranging from 15 to 49. The age pattern of women shows that nearly half of them are below 39 years of age, of which most of the women are in the age group years (32.7%). That is, half of the populations in the sample are young. The lowest (2.0%) and highest age groups (4.0%) constitute a small percentage of women. The youngest category of women in our sample (15-19) would have been married earlier. Age at marriage In a society like Kerala marriage has been regarded as the point of initiation of sexual activity, and therefore the beginning of exposure to reproduction. So the age at marriage pattern seems important in the present study. The age at marriage shows that most of the women were married in the age group years (43.7%). The highest age groups constituted a small percentage of women (2.7%). This implies that most of them started their child bearing and rearing in their adolescent age itself. This is a general trend in Kerala as far as rural area is concerned. This has a bearing on the status of reproductive health of these women. 147

4 Education Education is considered as an important social characteristic. Education enhances the capacities and capabilities of individuals to a large extent. It also influences the style of life, occupation and adjustment pattern of people. The behavior pattern and thinking of educated persons is different from illiterate or semi-educated people. Likewise the educated women are assumed to be well-off when compared to the semi educated or illiterate women in all respects especially in the area of general awareness and health related matters. The direct and indirect paths through which female education influences reproductive behavior are numerous. Education is associated with later entry into marriage, preferences for smaller families, spacing, and planning the second childbirth, increased awareness, acceptability and use of contraception. Education has long been recognized as a crucial factor influencing reproductive behavior (UN, 1996). So in our analysis, the variable levels of education of respondent and her husband have been given due importance. In our sample 7.3 percent of women and 3.3 percent of their husbands were illiterate. This is a contradictory result in a sample from an almost fully literate state, Kerala. Most of the literates had only school education irrespective of their gender. The proportion of higher educated persons is comparatively lower in the sample (0.3%). This can be attributed to their rural background where much stress was given to marriage and 148

5 immediate conception after marriage than to education and employment as far as girls are concerned. Occupation Occupation of an individual provides her not only a source of livelihood but determines her status and position in any society. Occupation determines her awareness, thinking and decision making in matters of reproductive health. In our sample 68.7 percent of women and 2.7 percent of their husbands were unemployed. The proportion of persons having higher occupational status is comparatively lower in the sample (0.7%). Religion Kerala society is divided on religious lines. Religion is an institution which instills values and a particular philosophy of life in individuals and in their outlook. Each religion has its own outlook, specific culture and specific behavior. In a culture and tradition-bound society like Kerala, religion plays a major role in deciding the reproductive behavior of women, their attitude towards health care and nature of food in-take throughout their pregnancy, delivery and post delivery periods. In our sample, Muslims predominate other religious groups i.e., 61 percent. About 22.3 percent of the women are Hindus and 16 percent of the women are Christians. This is because we fixed our parameters for stratification first and then went for sample selection and this landed us in Muslim dominated areas. However, this has not marred the validity of our study as our analyses and findings are based on average 149

6 Income Income also plays an important role in socio-cultural analysis. Our sample shows that the monthly family income of the vast majority respondents (76.3%) is below Rs It was only 23% who belong to the highest income group of above Rs 10,000. This shows that majority of the respondents are in the BPL category. Since the level of poverty determines the health behavior of a community, income constitutes a determining factor in the health of our respondents. Place and type of delivery Place of delivery shows the attitude of the respondents and the family members towards their reproductive health. In our sample 44.7 percent of women had their delivery in private hospitals while 41% in government hospitals. The reproductive health of women is, generally, very much related to the type of deliveries they had. In our sample 86.3 percent of women had normal delivery; with least complications the rest (13.7%) had caesarian delivery. 150

7 Table: 5.1. Socio cultural profile of the respondent Background Characteristics Age Age at marriage Education of Respondent Husband s Education Occupational level of Respondent Percentage Below and above 2.7 Illiterate 7.3 can read and write 30.7 High school 53.0 Higher Secondary 6.3 Graduate 2.3 Post Graduate 0.3 Illiterate 3.3 can read and write 48.7 High school 39.7 Higher Secondary 6.3 Graduate 2.0 Unemployed 68.7 Blue collar 9.7 White collar 4.3 Business 3.7 Professional 0.7 Unorganized sector

8 Husband s Occupation Religion Income Place of delivery Type of delivery Unemployed 2.7 Blue collar 10.7 White collar 7.0 Business 35.7 Professional 0.3 Unorganized sector 42.0 Hindu 22.3 Muslims 61.0 Christians 16 Below , Above 10, PHC 6.0 Private Hospital 44.7 Govt. Hospital 41.0 Home 8.3 Normal 86.3 Caesarian 13.7 These variables are supplemented by other related variables in the analysis of our problem. They are vitally related to the problems in reproductive health. The present chapter deals with the social and cultural characteristics of our respondents and their influence on problem relating to reproductive process. The different problems associated with reproductive health and the 152

9 prevalence of different elements of reproductive morbidity are discussed and analyzed. We have tried to show the extent to which and the processes through which socio-cultural dimensions influence the different elements of reproductive health. Since our objective has been to map out all relevant variables associated with a woman s reproductive health and since this extended beyond obstetrics into the gynecological area, we have extended the sweep of our study into these related areas as well. In this effort, we have identified all major medical problems of our respondents associate with reproductive health. Sexually transmitted diseases associated with abortion, contraception, childbirth and so on are facets of widespread but largely neglected problems in women s reproductive health sector. Taken together, illnesses and deaths arising from complications of pregnancy, childbirth, unsafe abortions, reproductive tract illness and improper use of contraceptives, top the list of reproductive health threats of women worldwide. Deaths and illnesses from reproductive disorders are highest among poor women everywhere. In societies where women are disproportionately poor, illiterate, and politically powerless, high rates of reproductive illness and death is the norm. Women in developing countries, and economically disadvantaged women in the cities of some industrial nations, suffer highest rates of complications from pregnancy, sexually transmitted diseases and reproductive concerns in the world. 153

10 Men also suffer from reproductive health problems, most notability sexually transmitted diseases, but the number and scope of risk is far greater for women than men for a number of reasons. 1. Women alone are at risk of complications from pregnancy and childbirth. 2. Women face higher risks in preventing unwanted pregnancy. They bear the burden of using (and suffering potential side effects) most contraceptive methods and they suffer the consequences of unsafe abortions. 3. Women are more vulnerable to contracting and suffering complications of many sexually transmitted infections due to unprotected sexual relationships. Complications of pregnancy, childbirth, and unsafe abortions are now the leading, killers of women in reproductive age throughout the third world. Recent research on reproductive health is unequivocal in establishing that men s attitude, behavior and the general level of inequality between the sexes in terms of their intimate behavior and social relationships affect women s ability to exercise their own choice in attaining positive sexual and reproductive health outcomes. Male dominance in physical, social and most significantly in sexual relationships - can put women at risk in terms of unwanted and risky sexual encounters, pregnancy and ill health. If the gender relations are better, more open and egalitarian, it is easier for both men and women to achieve and maintain better sexual health and manage their 154

11 reproductive lives free from coercion and fear; these were widely held social goals expounded at the 1994 International Conference on Population and Development (ICPD) in Cairo and the 1995 Fourth World Conference on Women in Beijing. Apart from intra-household dynamics of power relations and decision making whereby men (along with other older members of the family), seem to take most decisions including those related to reproductive health issues, usually with adverse implications for women s health, other social changes warrant a redefining of traditional gender roles. Pregnancy Waste The pregnancy wastage is a good indicator of reproductive health of mothers. Pregnancy wastage includes still birth and abortion. When abortion is taken into consideration, it is important to consider the type of abortion since it is related to reproductive health. Natural abortion is very much related to bad reproductive condition of women than in the case of induced abortion. In our sample, 6 percent of women experienced induced abortion while 12 percent had natural abortion. In the case of induced abortion most of the women preferred D and C method. Induced abortion is an indicator of health awareness and level of control of the respondents over their body since abortion itself is damaging the uterus and reproductive organs of the individual. 155

12 The reproductive health of women, especially the health problems they experienced relating to childbirth and reproductive morbidity condition they experienced at the time of the survey are given particular emphasis in this chapter. Here we try to analyze whether the socio-cultural variables have direct impact on the morbidity pattern during the reproductive period. Reproductive Health Problems Since we have approached reproductive morbidity in a holistic manner, in this section, we discuss the various reproductive health problems of the respondents during pregnancy, in the process of delivery and after delivery. This will give continuity to the disease pattern associated with reproductive health and also help to examine the carryover of some of the diseases from pre natal to post natal period. We have assumed that if proper health care was taken during the pre natal and natal periods, many of the post natal morbidities would have been eliminated or at least their severity could have been reduced. This is the logic in bringing some of the ailments of the pre natal and natal periods for consideration in the present chapter. Table 5.2 gives the percentage distribution of pre-natal problems experienced by the respondents. 156

13 Table: 5.2. Percentage distribution of pre-natal health problems Problem during pre-natal period Percentage Edema in hands and legs 20.7 % Trouble with vision 3% Vertigo 1% Convulsions 2.3% Burning/ pain during urination 10% Varicose vein 6.7% Fever lasting more than 3 days 8.3% High blood pressure 9% Vomiting that needed Treatment 23% Diabetes 5.7% Bleeding 9% Abnormal white discharge 16% Some women in our sample were prone to have some heath problems during their pre-natal period. The symptoms commonly found are: edema in hands and legs, trouble with vision, vertigo, convulsions, pain during urination, varicose vein fever lasting more than 3 days, high blood pressure, vomiting that needed treatment, diabetes, bleeding, abnormal white discharge, weakness or tiredness, weak or no movement of fetus etc. The most prevalent problems among the sample are vomiting (23.0%) and edema in hands and legs (20.7%), as it is a common symptom during pregnancy which can also 157

14 lead to hypertension and related complication in later stage. In normal case this is not serious. 9 percent of women experienced high blood pressure and 5.7 percent experienced diabetes. Among the whole sample of mothers 53 percent of the women experienced at least one health problems during their pregnancy period. Tabled 5.3 give the percentage distribution of the problems of our respondents during the time of delivery. Table: 5.3. Percentage distribution of problems during delivery Problem during delivery Percentage Labor lasting more than 18 hours 12.7% Excessive bleeding 7.7% Loss of consciousness 9% Convulsions 1.7% Breech presentation 5.7% Twins 3.3% Teat of vagina 2% At the time of delivery one has to face the most pleasant as well as the most cruel and dramatic moments of life. It is a natural thing that most of the beings in the world give birth to children. But it is surprising to note that such a common process may turn vulnerable and its cruel hands affect maternity in the human being very much. Any way delivery of a woman is a complicated process. Labor lasting more than 18 hours, excessive bleeding, loss of 158

15 consciousness, convulsion s, breech presentation, twins, teat of vagina etc are some of the problems during delivery. Here in our study the problems during delivery are not much prevalent as during pregnancy. It was found in the sample that 12.7% of the respondent faced the problem of labor pain lasting more than 18 hours. 9% lost their consciousness and about 7.7% excessive bleeding. In the sample the most prevalent problem is Labor lasting for more than 18 hours. 5.7 percent of respondents experienced the problem of breech presentation and 7.7 percent had excessive bleeding. The analysis brought to light the factor that 32 percent of the respondents experienced some health problem during their natal period. Since most of the deliveries were institutional, most of them who have problem during delivery would have received care from hospitals, where they have had their deliveries. In Table 5.4 we give the distribution of respondents according to the problems they faced during the post natal period. Table: 5.4. Percentage distribution of post natal problems Problem during post-natal period Percentage Sepsis in Vaginal tear 2.7 % Fever which lasted for more than 3 days 4% Loss of consciousness for more than 15 minutes 4.7% Lower abdominal pains 12% Pain during urination 8.3% 159

16 Psychological problems (depression, anxiety etc) 14.7% Convulsions 0.7% Abdominal white discharge 6.3% Bleeding 8.7% Usually there are post delivery health problems in the case of many women. Hence, the respondents were asked whether they had any complications soon after delivery or within one week after the delivery. Just as delivery complications. postnatal complication are also dangerous to the women and the infant. The specific problems include sepsis in vaginal tear, fever which lasted for more than 3 days, loss of consciousness for more than 15 minutes, lower abdominal pain, pain during urination, psychological problems (depression, anxiety etc), convulsion, abdominal white discharge, bleeding, severe headache etc. The prevalence of these problems among women is much higher during delivery but lower during pregnancy. Among the whole sample. 36 percent of the respondents experienced health problem during their post natal period. The most prevalent problems experienced were lower abdominal pain (12%) and psychological depression (depression and anxiety) (14.7%). Socio-cultural factors in reproductive health problems Several background factors may influence the health problems during women s reproductive span. Here, we relate the socio-cultural factors with the 160

17 reproductive health problems of women in the post natal, period. Even though the problems we were concerned with are of biological nature, social and cultural factors may have some influence in the occurrence and persistence of such problems. So we looked into the socio-cultural contexts in which these problems occurred. Table 5.5 gives the relationship between present age and reproductive health problems related to childbirth. Table: 5.5. Present age and reproductive health problems related to childbirth Age positively reported to have reproductive health problems During pregnancy During delivery After delivery % 16.7% % 30.8% 61.5% % 30% 36.7% % 31.7% 27.6% % 33.3% 40.4% % 36.2% 41.1% % 33.3% 41.7% When the problems were analyzed with age (Table 5.5) it was found that among the young age group of and among the higher age group of 45-49, 66.7 percent of the respondent have experienced reproductive health problems during their pregnancy period. This shows that the young age groups who were in their teens and the upper age group who where in the risk 161

18 category experience reproductive problems comparatively higher than those in the other age categories. Age-wise analysis of the problems during delivery showed that a large section of the respondent in the upper age group of (36.2%) have experienced problems during delivery when compared to the young age group of (16.7%). This may be due to their failure in conducting periodic check-ups during pregnancy period, which could be attributed to their illiteracy. When the reproductive health problem after delivery period was analyzed with age it was found that majority of the respondents (61.5%) in the younger age group of have experienced reproductive health problems after their delivery time, when compared to other age groups. This may be due to the fact that they are not approaching hospitals for their post natal check-ups, which may be due to their illiteracy and ignorance. From the above analysis of the table it can be concluded that majority of the respondents are facing reproductive health problems during their pregnancy period when compared to the delivery or post delivery period. The major problems faced by the respondents during this period are excessive vomiting, edema in hands and legs and abnormal white discharge. Chi square test showed significant relationship between age and other variables, viz., problems at different stages of reproductive health. 162

19 In Table 5.6 we give data on age at marriage and health problem at different stage of reproductive period Table: 5.6. Age at marriage and reproductive health problems related to child birth Age at marriage positively reported to have reproductive health problem During pregnancy During delivery After delivery Below % 31.1% 31.1% % 25.8% 34.9% % 41.2% 44.6% 25 and above 25.0% 50.0% 37.5% When reproductive health problems of respondents were analyzed with their age at marriage (Table 5.6) it was found that a large section of below 15 age group (45.8%) were seen to have problems during their pregnancy period. This was 56.2 percent in the case of age at marriage group. At the same time half of the respondents (50%) in the age at marriage group of above 25 were seems to have problem during delivery. Among age groups it was found that 44.6 percent had problem after delivery. The present age and age at marriage show a varying trend with the problems. It is evident from table 6.5 that higher percentage of women experienced some reproductive health problem during pregnancy than during delivery and after delivery. As the age at marriage is increasing, the delivery complications are also increasing. It may be due to the fact that women who become pregnant at a later age have a 163

20 higher risk of developing gestational diabetes and blood pressure during pregnancy. Table: 5.7. Education and reproductive health problems related to child birth Education positively reported to have reproductive health problem During pregnancy During delivery After delivery Illiterate 68.2% 63.6% 57.9% can read and write 43.8% 27.5% 30.3% High School 54.8% 25.2% 37.9% Higher Secondary 78.9% 63.2% 42.1% Graduate 50.0% 85.7% 57.1% Post graduate 100% - - When the reproductive health problems of respondents were analyzed with their education (Table 5.7) it was found that a large section of postgraduate respondents (100%) were seen to have problems during their pregnancy period. This was 68.2 percent in the case of illiterate respondents. At the same time 85.7% graduate respondents have problems during delivery. It was also noticed that among the illiterate, 57.9 percent were having problem after delivery. This analysis brought to light the fact that all post graduate respondents faced problems during their pregnancy but no one experienced reproductive health problem during and after delivery. Education had influence on the occurrence of the problems under consideration. 164

21 As the level of education increases their age at marriage also increases. This will lead to their getting pregnant at a later age. This in turn will lead to complications during pregnancy and during delivery. This explains the pregnancy complication among post graduates and delivery complication among graduates. At the same time in the case of the illiterates their poor awareness, lack of nutritious food and proper rest and lack of concern over their health might have contributed to their having problems after delivery. Table: 5.8. Occupation and reproductive health problems related to child birth Occupation positively reported to have reproductive health problem During pregnancy During delivery After delivery Unemployed 53.0% 26.6% 34.5% Blue collar 48.3% 37.9% 39.3% White collar 58.3% 75.0% 53.8% Business 63.6% 50.0% 50.0% Professional 50.0% 50.0% - unorganized sector 61.1% 40.5% 48.5% Occupation and reproductive health problems related to child birth are shown in Table 5.8. Majority (63.6%) of the respondents who are doing business were found to have experienced problem during their pregnancy period, which was followed by (61.1%) respondents working in unorganized 165

22 sector. This may be due to the fact that these respondents might have tension and irregular life schedule due to the nature of their work. Further analysis showed that a vast majority of the respondent (75%) who were engaged in white collar jobs followed by 50 percentage each of the respondents engaged in business and professional occupations had child birth problems. This may be due to the type and nature of occupation they are engaged in that might have led to their lack of involvement in getting timely medical check-ups and proper medication. In any case we can say that their problems were related to their occupations. This analysis also showed that majority of the respondent who were doing white collar jobs and 50 percent of the business persons were facing problems after their delivery. This may be due to the fact that the nature of their occupation demands more time and involvement of the respondents. So they are not getting sufficient care and rest. Table: 5.9. Religion and reproductive health problems related to child birth Religion positively reported to have reproductive health problem During pregnancy During delivery After delivery Hindu 53.7% 36.4% 36.4% Muslim 53.1% 26.0% 34.5% Christian 58.3% 52.2% 51.2% Religion and reproductive health problems related to child birth are shown in Table 5.9. It is evident from the table that in all religions higher 166

23 percentage of women experienced some problems during pregnancy. But this was not the case during delivery and post natal periods. Here however, Hindus showed the same rate (36.4%) at delivery and post delivery periods. Christians showed consistency at higher level during the two later events (52.2% and 51.2%). However Muslims showed very low rate (26.0%) during delivery and slightly higher rate during the post natal period (34.5%). There is less difference among Hindus and Muslims who had some health problems after delivery. As stated earlier, Hindus and Muslims depend more on Ayurvedic and traditional medicines that help to increase their physical health during the post delivery period. It may be stated that, among the three communities in our study, Hindus and Muslims were found to use more Ayurvedic and traditional medicines for their morbidity than the Christians. At the same time Christians who are more depending upon modern medicine are not giving due important to the traditional mode of pregnancy care. This might have contributed to their complications at all stages of child birth when compared to Hindus and Muslims. Chi Square test shows that there is significant relationship between the variables under examination. 167

24 Table: Income and reproductive health problems related to childbirth Income Positively reported to have reproductive health problem During pregnancy During delivery After delivery Below % 36.6% 37.5% % 25.4% 34.8% % 37.8% 44.7% Above % 45.2% 40% When reproductive health problems of respondents were analyzed with their income (Table 5.10) it was found that a large section of Rs income group (71.1%) were seen to have problems during their pregnancy period. This was 50 percent in the case of the above Rs.10, 000 income group. At the same time 36.6 percent of the below Rs. 10,000 income group were seen to have problems during delivery. Among the Rs income group it was found that 34.8 percent were having problem after delivery. It is evident from the table that irrespective of the income level under consideration, higher percentage of women experienced some problems during pregnancy than those who had experienced one or more problems during delivery or after delivery. These results show that the socio cultural factors under consideration have exerted much influence on the occurrence and persistence of the reproductive health problems during pregnancy, during delivery and after delivery. Our assumption that many of the reproductive health problems 168

25 persist throughout the reproductive period has been proved true as the above tables show, They belong to a period from the time of pregnancy to the present time when we interviewed our respondents, and over period commencing from age 15 and ending with age 49 which was the lower and upper age limit of our sample respondents. Reproductive Health Problems experienced and treatment taken Here we consider the treatment taken by the respondents who had experienced any reproductive health problems during pregnancy and after delivery. The nature of treatment is not taken into consideration, since most of the deliveries are institutional. Table 5.11 shows the problems experienced by the respondents during pregnancy and treatment taken by them. Table: Problems during pregnancy and the treatment taken for them Problem during prenatal period percentage Treatment having the problem Taken Not taken Edema in hands and legs 20.7% 3.7% 16.7% Trouble with vision 3.0% 0.7% 2.3% Vertigo 1.0% - 1.0% Convulsions 2.3% 0.7% 1.3% Burning/ Pain during urination 10% 1.7% 8.3% varicose vein 6.7% 2.3% 4.3% Fever lasting more than 3 days 8.3% 7.0% 1.3% 169

26 High blood pressure 9.0% 8.3% 0.7% Vomiting that needed Treatment 23.% 5.7% 17.3% Diabetes 5.7% 5.3% - Bleeding 9.0% 6.7% 2.0% Abnormal white discharge 16.0% 4.0% 1.7% The percentage distribution of mothers who had experienced one or more problems during pregnancy and the treatment taken are shown in table5.11. This table shows that the main problems found in the prenatal periods were Edema in hands and legs (20.7%) and vomiting (23%). In prenatal period the treatment taken for edema in hands and legs is only 3.7 percentages and treatment taken for vomiting is 5.7 percent. In prenatal period 8.3 percent women had taken treatment for high blood pressure. Table: Problems after delivery and the treatment taken for them Problem after delivery percentage Treatment having the problem Taken Not taken Sepsis in vaginal tear 2.7% Fever which lasted for more than 3 days Loss of consciousness for more than 15 minutes 4.0% 4.7% Lower abdominal pains 12.0% Pain during urination 8.3%

27 Psychological problems (depression anxiety) 14.7% Convulsions 0.7% Abnormal white discharge 6.3% Bleeding 8.7% The main problems found in the postnatal period (Table 5.12) are the psychological problems (14.7%) and lower abdominal pain (12%) in which the treatment taken for this problems is very less i.e., only 0.7% women were taken treatment for lower abdominal pain. The main reason for not taking treatment on the former is that most of the women believe that these postnatal problems were quiet natural and medical treatment was not necessary. Socio Cultural factors and treatment taken during pregnancy Social and cultural factors might have influenced the women s awareness about the availability of treatment for the problems and whether they seek medical help or not. The following tables 5.13 to 5.15 show the treatment taken during pregnancy for the problems they had by socio-cultural factors. 171

28 Table: Education and health problems during pregnancy and treatment taken Treatment taken during pregnancy Education of Respondent Edema in hands and legs Burning/ pain during urination Fever lasting more than 3 days High blood pressure Vomiting Bleeding Abnormal white discharge Varicose vain illiterate % % - - can read and write 13.3% - 75% 85.7% 13.3% 100% 50% 16.7% High School 15.8% 19% 91.7% 100% 25.5% 82.4% 83.3% 50% Higher Secondary 25% % 28.6% 100% - 100% Graduate 100% 100% - 100% 100% 100% - - Post graduate 100% % A look at Table 5.13 shows that for most illnesses, the illiterates did not take any treatment, while graduates took it. Also as education increases, the respondents treated their illness selectively according to their feeling of seriousness of these diseases. High blood pressure and bleeding belong to this category. When the treatment taken during pregnancy of the respondents was analyzed with their educational level it was found that all graduate and post graduate respondents (100% each) were seen to have taken treatment for the two diseases during their pregnancy period. At the same time none of the illiterate respondents has taken treatment for this ailment during pregnancy 172

29 period. Blood pressure and bleeding had 100 percent taken from these three categories. In the case of burning pain during urination it was found that 100 percent of the graduate respondents had taken treatment while it was only 19 percent in the case of high school educated and none in the case of illiterate. For those respondents who had fever lasting more than 3 days it was found that 91.7% respondents who have high school level education had taken treatment followed by 80 percent of the illiterates. It was found that by and large as education increased the percentage of women who sought medical help for their health problems during pregnancy also increased. The educational level of the respondent increased their awareness about reproductive health problems and naturally they go for medical treatment during pregnancy period. Higher educational groups are giving more importance to their pregnancy related problems by consulting doctors and taking treatment because they are aware of the gravity of the problem through their educational attainment and also they may be having better economic base to meet the medical expenses whereas in the case of illiterates and semi-illiterates due to lack of awareness they are neglecting such problems and justifying such problems are common to all pregnant women.. 173

30 Table: Income and health problems during pregnancy and treatment taken Treatment taken during pregnancy Income Edema in hands and legs Burning/ pain during urination Fever lasting more than 3 days High blood pressure Vomiting Bleeding Abnormal white discharge Varicose vain Below % 16.7% 90% 83.3% 23.1% 50% 55.6% 40% % 5.9% 72.7% % 70% 85.7% 14.3% , % - 100% 87.5% 33.3% 100% 100% 66.7% Above 10, % 75% - 100% 75% 100% - - Table 5.14 shows that more high income groups sought medical help for the problems during pregnancy than low income groups. This is because health care is costly but when income increases, it becomes affordable. Due to better awareness and better income they are giving serious concern to their pregnancy related ailments. So they go to hospital for medical check-up during pregnancy. Table: Religion and health problems during pregnancy and treatment taken Treatment taken during pregnancy Religion Edema in hands and legs Burning/ pain during urination Fever lasting for more than 3 days High blood pressure Vomiting Bleeding Abnormal white discharge Varicose vain Hindu 11.8% 12.5% 100% 100% 13.3% 60% 100% 40% Muslim 20.5% 13.3% 73.3% 82.2% 21.3% 73.3% 66.7% 23.1% Christian 16.7% 28.6% 100% 100% 83.3% 100% 50% 100% 174

31 Religion and percentage distribution of mothers who had experienced some health problems during pregnancy and treatment taken are shown in table In high blood pressure the treatment taken during pregnancy is 82.2% among Muslims and among Hindus and Christians it was 100 percent. The treatment taken for bleeding is 60% among Hindus, 73.3% in Muslims and among Christians it was 100 percent. The above analysis showed that irrespective of religion all respondents are getting treatment for clinical conditions like fever lasting for more than three days, high blood pressure, bleeding and abnormal white discharge. This may be because during pre-natal check-ups they were forced to undergo medication by the health care centers. But in the case of common problems like edema in hands and legs, burning pain during urination, vomiting, varicose vein etc. Christians were found to have undergone treatment more when compared to other religious groups. The same trend was seen in post natal period also. It was found that as age increased the percentage of women who seek medical help for their health problems after delivery, also increased. The highly educated respondents sought better medical help for their health problems after delivery, may be due to their higher exposure to the problems that can occur after delivery and the possibility that such problems may lead to post delivery complications. As education increases, the awareness about reproductive health problems also 175

32 increases. It is found that more high income groups sought medical help for their problems after delivery than low income groups. This is because as income level increased, the educational level also was increasing. If the educational level is increasing, the awareness about reproductive health problems is also increasing. Reproductive Morbidity Reproductive morbidity refers to health problems related to reproductive organs and functions, including and outside of childbearing (Zuragk et al., 1993). It covers both gynecological and obstetric morbidity as well as related morbidity, such as urinary tract infections, anemia, high blood pressure and obesity. Gynecological morbidity includes reproductive health problems outside pregnancy, like RTIs, menstrual problems, cervical ectopy (erosion), infertility, prolapse and problems with intercourse. Obstetric morbidity refers to ill health in relation to pregnancy. Research in India shows that poor women carry a heavy burden of reproductive morbidity. A significant component of such morbidity is unrelated to pregnancy and is due to reproductive tract infections, many of which are sexually transmitted. These reproductive illnesses among women are invisible because of the culture of silence that surrounds them and women do not have access to health care for these illness. As past programmers recognized women only as mothers, many women were not treated and many reproductive health problems were not addressed (Pachauri, 1994). 176

33 Most of the studies available on reproductive morbidity are based on information from clinics or hospitals, but because a large proportion of women typically do not visit such facilities, results do not reflect the true magnitude of the problem (Bhatia and Cleland, 1995). Another advantage of self reports of morbidity symptoms is greater ease of data collection and much less costly than studies that collects clinical and laboratory data. But a self reported symptom accounts for the possibility of over reporting of symptoms. This is sometimes problematic, because the women s reports and findings from the clinical and laboratory examinations may not match. In the past, the usefulness of data on self-reported morbidity had been questioned. Though medical scientists naturally prefer to estimate the prevalence of scientific diseases through clinical examination and laboratory tests, such procedures are usually too expensive to be carried out on a large scale in community settings (Bhatia and Cleland, 1995). But in a society like ours, women bear the symptoms of these morbidity conditions silently without seeking any health care, which may reflect lack of awareness and fatalistic approach. Self reported symptoms have its relevance and utility. In the present study, one limitation of studying reproductive morbidity is that we consider only symptomatic women with the assumption that asymptomatic women are uninfected. This assumption is generally not always true. And also almost all the symptoms tend to overestimate the true prevalence. 177

34 In Kerala, studies on reproductive morbidity are very few. This section intends to clarify the objective first to determine the level of reproductive morbidity using self- reported symptoms and then to analyze the sociocultural correlates of these morbidities. In this section, we discuss various gynecological problems confronted by the respondents. Table: Distribution of respondents and their Gynecological problems Gynecological Problem Frequency Percentage Irregular menstruation Painful menstruation Excessive bleeding during menstruation Absence of menstruation Excessive white discharge Foul Smelling discharge Itch in Vaginal area Pain during intercourse Sepsis in vagina Protepse of Uterus Burning/ sensation during urination Pain during urination pus in urine urinary incontinence This table (Table 5.16) show that majority of the respondents (54.3%) said that they faced gynecological problems. Some of the gynecological 178

35 problems of our respondents are irregular menstruation (10.7%), painful menstruation (5%), excessive bleeding during menstruation (16.7%), absence of menstruation (1%), excessive white discharge (9%), foul smelling discharge (9.3%), itch in vaginal area (20%), pain during intercourse (11.7%), sepsis in vagina (2.7%), protepse of Uterus (1.3%), burning sensation during urination (3.7%), pain during urination (5.7%), pus in urine (8.3%), urinary incontinence (9%) etc. The analysis showed that the most prevalent gynecological problems are itching in the vaginal area (20%), excessive bleeding during menstruation (16.7%), and pain during intercourse (11.7%) and irregular menstruation (10.7%). This analysis brought to light the fact that excessive white discharge is the most serious and common health problem that was found among the respondents. But only 9 percentages of the respondents were ready to report it. Discussions with the respondents suggest that women perceive white discharge to be part of sexual maturation and consider it as normal. For instance, according to one respondent, like every tree has flowers, every woman will have white discharge except it s not soothing like a flower. Respondents commonly have multiple terms to refer to different types of discharge. In terms of severity, some women reported discharge in general as the most severe illness, while in some areas respondents reported different forms of discharge. Respondents in our study linked discharge to other illnesses, like general weakness and backache, and used such terms as 179

36 euphemisms to refer to discharge. But they refrain from discussing these matters with doctors. The reasons for this were shyness and embarrassment especially, in some settings, where discharge is associated with immoral behavior either on the part of the women or her husband. Respondents also reported to have clusters of symptoms that they reported together because they experienced them concurrently. Earlier studies (eg. Bhatia, 1995 and Wasserheit et al, 1989) indicated that reproductive tract infection was more prevalent than other reproductive morbidity conditions. Our analysis also confirms the prevalence of reproductive tract infections (RTI) among our respondents as a very prevalent form of morbidity. Socio-cultural factors and reproductive morbidity Several background factors may influence the reproductive morbidity conditions of women in rural Kerala. Here we relate the socio-cultural problems with the gynecological problem of women. Even though the problems we were concerned with are of biological nature, social and cultural factors were found to have some influence in the occurrence of these problems. So we have looked into the socio-cultural dimensions in which the problems occurred. 180

37 Table: Current age and gynecological problems Age Total Gynecological problems Yes No Total % % % % % % % % % % % % % % % % When the gynecological problems of the respondents were analyzed with their age (Table5.17) it was found that majority of the respondents (61%) who were in the age group were found to have gynecological problems while in the case of adolescent respondents it was 33.3 percent. It was also noticed that 58.2 percent of the respondents in the age group experienced gynecological problems. This shows that the gynecological problems increase with age. This may be due to the fact that the respondents in their higher ages are facing menopausal disorders combined with lack of post natal care and rest and this might have resulted in such problems. The prevalence of high percentage of RTI among the respondents shows the neglect of the social and cultural dimension of reproductive health. 181

38 Culturally there is a tendency on the part of girls and women in our study area to use old cotton cloths to absorb the menstrual blood flow. Although they may replace and wash these cloths frequently they show a tendency to dry it in unhygienic surroundings. This may cause low grade reproductive tract infections (RTIs) if the cloths are not cleaned and dried thoroughly before being used again it can get infected. This is a major problem of adolescent girls who are not sexually active and are unaware of the consequences and hence unlikely to seek treatment for RTIs. It was found that majority of the respondents are using cotton clothes during menstrual period and more than 90 percent of them are reusing it. Reusing of cotton for more than three times is unhygienic. This seems to be one of the factors for getting reproductive tract infections. Table: Age at marriage and gynecological problems Gynecological problems Age at marriage Below % % % 25 and above % Total % Yes No Total % % % % %

39 When the gynecological problems of respondents were analyzed with their age at marriage (Table 5.18) it was found that majority of the respondents in the age group of (60.6%) were seen to have gynecological problems whereas it was only 50 percent among the high age group of 25 and above. By and large, there seems to be no difference between age groups in the matter of gynecological morbidity and Chi Square test also supports this. However, when we find that 53,2% of those married before age 15 had problem this has to be viewed seriously because at this age one does not expect this high frequency. So better attention should be given to adolescent mothers because of the women s low age at marriage and the growing trends among younger women to complete their reproductive span in a relatively shorter time. Respondents who were married in their teens had reported that they were unprepared and unprotected during their first sexual activity. Girls who marry early begin sexual activity when they are physiologically more vulnerable to infection. Tremendous pressure is exerted on girls to get married upon reaching menarche. In many parts, early marriage for girls is a religious and social imperative. Despite laws that specify the legal age at marriage for girls as 18 years, cultural pressures often force parents to marry their daughters at younger age. Early marriage, pregnancies and motherhood result in acute health risks leading to maternal and infant /child deaths. Miscarriages, low birth weight babies, excessive bleeding, 183

40 infections are severe damage to the reproductive tract. Most adolescents tend to be extremely unaware of their own bodies, their health, physical well being and sexuality. Majority of the girls did not know about menstruation until its onset. It is observed that knowledge about reproductive health; the natural process of puberty, pregnancy or reproduction is very poor. The lack of knowledge about reproductive health has great consequences for the country. The main source of information about reproductive health is through their friends. Therefore young mothers should be given special care and attention to make them aware of the possible infections during the reproductive period. Education may have some relationship with the women s morbidity condition. High education improves awareness and recognition of symptoms of illness. Hence the educational levels of the women respondents in this matter were also taken into consideration. Table 5.19 shows that 63.6% illiterate women suffer gynecological problems. These results are similar to the findings from the other studies like a study by Bhatia and Cleland, 1996 in South India and Mayank et al. in New Delhi, 2001, and Matsu Mara and Gubhajn in Nepal,